| NPI | 1609827179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: MI 4301004601) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004601) |
| Enumeration Date | 2006-05-12 |
| Last Update Date | 2022-04-14 |